Correspondence

Mandatory HIV Testing for the Mentally Ill

N Engl J Med 1997; 337:1014-1015October 2, 1997

Article

To the Editor:

We are concerned that readers of the review by Rotheram-Borus of AIDS and People with Severe Mental Illness: A Handbook for Mental Health Professionals (May 1 issue)1 will not understand the contents of our book.

Rotheram-Borus emphasizes the issue of mandatory testing for the human immunodeficiency virus (HIV), which is not a major focus of our book. She asserts that “mental health providers will be pushed to institute programs of mandatory testing” as soon as word gets out about the high rates of infection among patients with mental illness. In fact, injection-drug users, whose infection rates are much higher than those of people with severe mental illness, are not subject to mandatory testing. Our position in favor of voluntary HIV testing, but in opposition to mandatory testing, is based on a long legal history of which Rotheram-Borus seems unaware. As the chapter on legal issues states, “the law maintains a general presumption that adults have capacity, and neither mental illness, hospitalization, nor involuntary commitment automatically rebuts the presumption.” To take up half of her review with a discussion of mandatory testing in this population has the unfortunate effect of suggesting that people with psychiatric illness should be singled out for such testing — a position that is not supported by either medical literature or the law.

Francine Cournos, M.D.
College of Physicians and Surgeons of Columbia University, New York, NY 10032

Nicholas Bakalar
Bronx, NY 10471

1 References

1. 1

   Rotheram-Borus MJ. Review of: AIDS and people with severe mental illness: a handbook for mental health professionals. N Engl J Med 1997;336:1332-1333
   Full Text

Author/Editor Response

Dr. Rotheram-Borus replies:

To the Editor: AIDS and People with Severe Mental Illness: A Handbook for Mental Health Professionals is an excellent primer on HIV and is not focused on issues of the early detection of HIV. The book provides a broad overview of HIV-related issues for mental health providers.

My review presented mandatory testing as only one example of the complex, shifting issues that will have to be confronted by professionals serving the mentally ill and, in fact, by all health care providers. The costs and benefits of the early detection, prevention, and treatment of HIV infection have shifted dramatically with the emergence of new antiretroviral agents and the results of the trial of zidovudine to prevent maternal–infant HIV transmission.1,2 However, having laws that guarantee self-determination for the mentally ill and informed, voluntary consent for HIV testing does not ensure cost-efficient and ethical solutions to the difficult social dilemmas that such laws generate. Clinicians and administrators need to work closely with community groups and officials at every level of government to translate the legislation into effective organizational procedures that are implemented with fidelity on a daily basis. The general guidelines in AIDS and People with Severe Mental Illness supply useful background information, but providers need to apply the guidelines to their particular settings. The book helps them to begin that process.

Mary Jane Rotheram-Borus, Ph.D.
University of California at Los Angeles, Los Angeles, CA 90024

2 References

1. 1

   Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994;331:1173-1180
   Full Text | Web of Science | Medline

2. 2

   Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. N Engl J Med 1996;335:1621-1629
   Full Text | Web of Science | Medline

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